Medical Record Audit Checklist

This comprehensive medical record audit checklist ensures clinical documentation meets regulatory standards for Joint Commission accreditation, CMS compliance, and HIPAA requirements. Complete all sections to verify patient chart accuracy, coding integrity, and consent documentation. Recommended for quarterly internal audits and pre-survey readiness assessments.

Industry: Healthcare
Frequency: Quarterly / Pre-Survey
Estimated Time: 25-35 minutes per chart
Role: Health Information Manager / Clinical Documentation Specialist / Compliance Officer
Total Items: 24
Compliance: Joint Commission, CMS Conditions of Participation, HIPAA Privacy Rule, AAPC Coding Guidelines

Patient Demographics

Verify accuracy and completeness of patient identification and demographic information.

Patient full name matches across all forms?
Date of birth correctly recorded and consistent?
Two patient identifiers present on every page?
Insurance and coverage information current and accurate?
Emergency contact information documented?

Clinical Documentation

Audit clinical notes for completeness, timeliness, and accuracy.

History of Present Illness (HPI) documented completely?
Assessment and plan documented for each encounter?
Physician signature and date on all entries?
Progress notes documented within required timeframe?
Discharge summary complete with follow-up instructions?

Medication Records

Verify medication documentation accuracy and reconciliation.

Medication reconciliation performed at admission?
Allergies and adverse reactions documented prominently?
Medication orders legible with dose, route, and frequency?
Medication Administration Record (MAR) complete and current?
Discharge medication list provided to patient?

Consent Forms

Verify informed consent documentation is complete and properly executed.

General consent for treatment signed and dated?
Procedure-specific informed consent obtained (if applicable)?
Risks, benefits, and alternatives documented on consent?
HIPAA authorization for disclosure signed?
Advance directive status documented?

Coding & Billing Compliance

Verify coding accuracy and billing documentation support.

Diagnosis codes supported by clinical documentation?
Procedure codes accurately reflect services rendered?
Medical necessity clearly documented for all services?
Modifiers used appropriately and supported by documentation?

Related Healthcare Checklists

Related Clinical Operations Checklists

Why Use This Medical Record Audit Checklist?

This medical record audit checklist helps healthcare teams maintain compliance and operational excellence. Designed for health information manager / clinical documentation specialist / compliance officer professionals, this checklist covers 24 critical inspection points across 5 sections. Recommended frequency: quarterly / pre-survey.

Ensures compliance with Joint Commission, CMS Conditions of Participation, HIPAA Privacy Rule, AAPC Coding Guidelines. Regulatory-aligned for audit readiness and inspection documentation.

Frequently Asked Questions

What does the Medical Record Audit Checklist cover?

This checklist covers 24 inspection items across 5 sections: Patient Demographics, Clinical Documentation, Medication Records, Consent Forms, Coding & Billing Compliance. It is designed for healthcare operations and compliance.

How often should this checklist be completed?

This checklist should be completed quarterly / pre-survey. Each completion takes approximately 25-35 minutes per chart.

Who should use this Medical Record Audit Checklist?

This checklist is designed for Health Information Manager / Clinical Documentation Specialist / Compliance Officer professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.

Can I download this checklist as a PDF?

Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.